Added Value

At times it seems as though the solution to every problem in the medical center is for the hospitalists to do it. At the University of California at San Francisco, my hospitalist colleagues lead efforts in information technology, quality improvement, perioperative care, transfers of patients to the medical center, and chair countless medical staff committees.

Given all these activities, it’s no wonder life as a hospitalist is busy. But these activities also add a richness and variety to work and place us at the center of the life of the hospital. As our field continues to grow, our responsibilities will continue to grow. In the years ahead, one challenge for our field will be to know when to say “no.”

As our field continues to grow, the responsibilities of hospitalists will continue to grow. In the years ahead one challenge for our field will be to know when to say “no.”

At an increasing number of hospitals across the country hospitalists add value in another important way by becoming involved with starting, staffing, and using palliative care services. Hospitalists already play a central role in caring for patients with life-threatening illness by providing expert symptom management and talking with them and their families frankly and compassionately about their illness, prognosis, and preferences for care. While this opportunity to affect the care of individual patients and their families is critical, we can better improve the care of these patients by participating in and leading efforts to establish palliative care services within our institutions.

For hospitalists, the arguments that support starting a palliative care service will be familiar because they involve many of the same issues as when starting a hospitalist program. It is helpful to consider why a hospitalist would want to undertake such an endeavor and why a hospital would support it. Here are the key issues:

1) Need: Many hospitalist programs are started to care for patients for whom there was not a doctor available. While inpatients who need palliative care may already have a doctor, the same argument about need applies. Simply put, the hospital is where half of Americans die and where others with serious, chronic, and life-threatening illness spend time. If for no other reason, palliative care services, like hospitalist programs, are necessary because so many patients need this care.

2) Quality: One of the most important drivers of hospitalist programs is quality. Because hospitalists focus on the care of hospitalized patients they can develop expertise and deliver higher quality. The same holds for palliative care. Studies demonstrate widespread shortfalls in

the quality of care that seriously ill and dying patients receive.1 In addition to doing a poor job managing pain, we typically fail to elicit and respect patient preferences. Just as a hospitalist program provides clinicians focused on the care of inpatients, a palliative care team consisting of physicians, nurses, a social worker, pharmacist, and chaplain provides expertise to address the broad range of issues that arise for patients and their families in a comprehensive and high-quality way.

3) Economics: Studies show that hospitalist programs can reduce length of stay and costs at similar quality.2 While cost-cutting is never the sole reason and often not the most important reason for starting a hospitalist program, the fact that these programs can reduce costs makes them financially attractive to hospitals. Palliative care programs provide the same financial advantages, usually with improved quality.

When given a choice, patients faced with a terminal illness will often choose care focused on symptom management and quality of life rather than longevity. Most often this care requires administering simple medications such as opioids, avoiding invasive procedures, and dedicating clinicians’ time to ensure that symptoms are well-managed, and the broad range of concerns are addressed. At UCSF and elsewhere palliative care programs consistently demonstrate cost savings.3 As our chief operating officer says, “We support palliative care because it’s the right thing to do. It helps that it reduces costs, but that’s not why we do it.”

4) Mission alignment: Hospitalist programs align beautifully with the mission of hospitals to provide high-quality, safe patient care at lower cost and with higher satisfaction. Many hospitals have other concerns that hospitalists help with, such as increasing throughput, managing unassigned patients, and improving care processes. Similarly palliative care programs improve the quality of care for patients with life-threatening illness, reduce costs, and increase patient and family satisfaction. Palliative care services also help with throughput by helping to transition patients to less intensive levels of care consistent with their preferences and expediting discharge to home and hospice.

5) Interdisciplinary skills: No hospitalist is an island. The effective hospitalist understands the benefits and necessity of working closely with colleagues from other disciplines to provide high-quality care. In the same way it requires an interdisciplinary palliative care team to address the range of issues facing patients from pain and symptom management to depression and anxiety to spiritual concerns to practical questions about how to get help at home and who will pay for it. The skills that hospitalists develop working with colleagues in the hospital are identical to those needed to provide palliative care.

WHY HOSPITALISTS MUST GET INVOLVED

The parallels between hospitalist programs and palliative care programs support the role of hospitalists in providing palliative care. But there are other important reasons for hospitalists to become involved with palliative care teams.

First, palliative care adds variety to work. Although it may seem that any given day already has too much variety, focusing on palliative care issues, and visiting with patients about their hopes and fears can be a welcome change from general hospitalist work. Second, palliative care can provide incredible personal rewards. Third, palliative care can add diversification to a hospitalist’s income stream through professional fees and hospital support directed at palliative care. Fourth, for the vast majority of us hospitalists who are generalists, palliative care offers the opportunity to develop special expertise and even board certification. Finally, a palliative care service in the hospital can increase the status of the institution, improving family satisfaction, addressing many JCAHO requirements, and supporting the bottom line.

As hospitalists we have many ways to get involved with a palliative care service. Those who are really motivated can lead the implementation of a palliative care service. Because only a minority of hospitals have palliative care programs, this opportunity will be available at many institutions.4,5 But even if you don’t want to lead the effort, you can still play a key role by joining an existing palliative care team or joining a team that is planning to start a program.

Palliative care programs can improve the care of seriously ill and dying patients. They address an important and unmet patient care need and mesh well with the mission and goals of nearly all hospitals. Hospitalists are perfectly positioned to participate in, lead, and use palliative care services. Such work not only helps our patients but benefits us as well by providing the rewards of helping patients and families in need. In the end, we gain not only from easing the suffering of our fellow human beings but from remembering how precious life is, how limited our time is, and how important our choices are about how we spend our time. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at UCSF.

REFERENCES

A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274(20):1591-1598.